Aug 17, 2010

What's the University of Chicago

Last week, I visited the University of Chicago, one of the first IHI Open School Chapters. On Friday morning, I met with student and faculty representatives to learn about the medical school and prepare for the M1 class we’d attend later that morning. The University of Chicago opened its doors to medical students in 1927 and welcomes approximately 88 new students each year. The first year medical students (M1) have only been on campus for two weeks. The class we attended was an orientation to the quality and safety track for the entire class of first year medical students.

Medical School: Quality & Safety Scholarship and Discovery Track
The students are introduced to each of the
Scholarship & Discovery tracks so they can decide whether or not they’d like to delve into research, receive mentorship, and do a project in one of five areas - scientific discovery, medical education, quality and safety, community health, and global health - during their four years in medical school. The Chapter helped design the Quality & Safety track and incorporated the IHI Open School courses.

Medical School: Quality Improvement Elective
As part of the Scholarship & Discovery track, students can take a quality improvement elective during the spring quarter of their first year. It’s a 10 week elective during which the students learn quality improvement tools and setup an improvement project. A couple of students presented their projects including one working with general medicine to develop developing checklists to prevent the CMS no pay events (they increased adherence to the quality indicators by 20%) and a second project that studied the time to antibiotics for pneumonia patients in the ER.

The class also included an overview of the Institute of Medicine’s definition of the six dimensions of quality, process mapping, data describing patient satisfaction with quality of care they receive and provider satisfaction with their ability to provide high quality care, the World Health Organization’s ranking of healthcare systems, and challenged students to look how hospital’s in their hometown faired on the Department of Health And Human Service’s HospitalCompare and the Commonwealth Fund’s WhyNotTheBest websites…and that was just the introduction to quality!

Chapter Meeting
After the orientation course ended, we ventured to the biomedical building for a lunchtime Chapter meeting attended by medical students, health administration and policy students, residents, and faculty. Since the Chapter was founded, it’s been led and focused on medical students, but is now developing a partnership with students from the Graduate Program in Health Administration and Policy and is also planning to engage pharmacy residents. This year, the Chapter is planning to focus on building an interprofessional network, with quarterly socials events, and giving students the opportunity to participate in a hands-on project. After some brainstorming, the students decided to pursue an improvement project that will focus on the referral system at a local women’s shelter and health clinic.

School of Social Services Administration
In addition to the medical students' exposure to QI, the Graduate Program in Health Administration and Policy (GPHAP), which is housed within the School of Social Service Administration and draws students from the Booth School of Business, the Harris School of Public Policy, and the School of Social Service Administration, introduces students to quality improvement. Students are required to take two of the IHI Open School Quality Improvment courses in their Special Issues in Healthcare Management course. Students also have the opportunity to use the IHI Open School courses to fulfill their co-curricular requirements during one of their academic quarters.

The students' early exposure to quality improvement and the support from the faculty on their campus is encouraging and exciting! We expect to see great things from this Chapter over the next year. If you’re a student or faculty member at the University of Chicago, check out their IHI Open School Chapter Website on Chalk!

Thank you to Vinny Arora, Andrew Schram, Greg Kaufman, Laura Botwinick, Julie Oyler, Lisa Vinci, Marcus Dahlstrom, and
the University of Chicago School of Medicine and GPHAP students and faculty for inviting me to your campus and hosting a terrific site visit!

Aug 15, 2010

Project Fives Alive: Two Days of Energizing Inspiration

Karni QI Team

In typical last-minute Eva fashion, two years ago, I decided to defer from medical school for a year to work at the Institute for Healthcare Improvement (IHI). IHI can be best described as a fast-paced social change organization that operates like a cross between a think tank and consulting firm that focuses on improving the delivery of health care through spreading systems redesign tools and interventions all around the world, including Ghana. As much as possible, IHI practices what it preaches. In addition to encouraging health care systems and health care professionals to employ the model of improvement to make the delivery of health care more efficient, reliable, and effective, all of IHI’s own work is continuously evaluated for improvement. After living and breathing quality improvement for a year, the transition to medical school, where the focus sometimes felt like mindless memorization of volumes of facts, was difficult.

My main motivation for coming to Ghana this summer to work on clinical quality and management research was to return to the field of quality improvement of health care. For the most part, my research has been very fulfilling as I have delved into answering the questions: what kinds of improvements can be made at the level of a district hospital to improve maternal health and how can those improvements be made? Since data is the backbone and currency of quality improvement, sometimes answering my objective questions has been frustrating because I continuously run into underdeveloped data and information systems. On the days that I felt particularly beat by data available to me, I’d wonder how IHI functions in Ghana.

Lambussie QI Meeting

IHI has three developing countries programs: Ghana, South Africa, and Malawi. In Ghana, Project Fives Alive, a partnership with the National Catholic Health Service (NCHS) and Ghana Health Service (GHS) is working towards reducing under five mortality through quality improvement. While I was working at IHI, the CEO, Don Berwick, made a short visit to Ghana and collected the most inspiring stories. Thanks to Nana Twum-Danso, Project Fives Alive director and Ernest Kanyoke, Project Fives Alive Project Officer, I had the opportunity to be inspired too.

Piina QI Team

Last week, I traveled to Wa in the upper west region of Ghana to join Project Fives Alive on two days of quality improvement (QI) meetings at various health centers and CHPS zones. It was a difficult journey up to Wa from Kumasi, but those troubles immediately melted away when I met Ernest. If it were possible to anthropomorphize quality improvement, Ernest would be the perfect model. He is brimming with energy and is whole-heartedly committed to quality improvement in his work and his everyday life. Upon arrival, when my hotel reservation was not processed correctly, Ernest immediately evaluated that this was due to a problem in hand-offs and he said he wished had time to help by first collecting data on how often this occurs. At the very least, seeing Ernest carry around a flip chart and colored markers conjured up feelings of comfort. IHI truly is flourishing in Ghana.

Lambussie Health Center

Because I arrived in Wa around 2:30AM and had to be up and ready for site visits at 7AM, Thursday’s meetings were tough. Immediately after Ernest’s more than deserved introduction of myself to the QI teams, I’d invariably fall asleep. I am still so ashamed that in response to the amazing work that these health centers are doing to reduce neonatal deaths, all I could give them was an inattentive, silent, sleeping Eva. Thankfully, even while sleeping, I think my brain was still alert and I gathered some truly remarkable accounts of the QI work being done by midlevel providers (midwives, community health nurses, and local support staff) to drastically improve the processes that can reduce neonatal mortality.

Samoa QI Team

For example, in Samoa, the two CHPS Zones have greatly improved their skilled delivery rate by making small changes to make delivering at a health center attractive for mothers. These changes include offering traditional porridge to the women after delivery. This small change does not just represent a inventive adaptation of traditional practices, but also sends the message that the health care staff cares about the well-being of the mother and that the health centers are welcome institutions. In Karni, the QI team discussed the progress of their intervention to reach out to women and develop a pregnancy plan to increase their skilled delivery rates, which are at a laudable 90+% and a very effective mosquito net distribution program that has reduced their rates of malaria admissions.

Karni QI Meeting

What impressed me the most was not the outstanding results and outcomes that these health centers can celebrate, but the dynamics of the QI meeting itself. The health center staff have no formal training in statistics, yet after just a few learning sessions, are very data driven. Midwives and community health nurses take turns contributing to and facilitating the QI meeting to discuss and evaluate the rates of first trimester registrants for prenatal care and improving postnatal care follow-up visits. During the meeting, their various registers (the raw data), are always open right in front of them and they reference the data throughout the meeting. The connection between data and the individual patient success narratives they are experiencing is strong and solid. I can’t say that even providers in the US have made this connection. The foundations of QI have been laid for these teams and with that, I believe that they can take on any health care delivery challenge.

Exuberant Ernest Working His Magic

All of this progress, however, could not have been possible without the skillful facilitation of the project officers. The project officers not only have a deep understanding of the individual process and quality measures and interventions that each health center is undertaking, but are also experts at managing relationships. Project Fives Alive is a partnership with the NCHS and GHS are extremely important agencies to work with for the success of its work. The project officer has mobilized and empowered all of the necessary stakeholders to participate in the shared goal of reducing under five mortality. A representative from the GHS district health office traveled with us and was present at every QI meeting. All levels of staff were asked to open their registers and discuss and interpret the data. And then together, the QI team would set aims and deadlines to meet before the next QI meeting. My own research experience has proven that this is no easy task. Building confidence and a positive attitude among the providers is on an entirely higher level. The hospitals that I visited were still struggling with just making sure all of the necessary stakeholders that would work together to improve maternal mortality were all available on the same day at the same time to just discuss maternal deaths. These project officers, like Ernest, have just the right combination of encouragement and persistence to have led the QI teams to where they are now.

Run-chart at Piina

The four sites that I visited were extremely resource deprived in comparison to the district hospitals that I have spent most of my time working with—most of the health centers do not have electricity! Yet, despite these resource challenges, look how far a statement like, “let’s take a look at the data” can go. The run charts and meeting minutes posted on the wall is really the only technology I saw that these facilities were using to achieve their results. It’s phenomenal. The next waves of the project are to expand and replicate the work being done in the northern regions to the rest of Ghana. This kind of exposure to QI has so much potential that I know whenever I have the opportunity to return to Ghana, the health care delivery system in Ghana will be positively unrecognizable.

The Fearless Issah

My site visits and time spent with the Project Fives Alive team was the perfect burst of inspiration that I needed as I begin to undertake my last small project before I have to return to Michigan. Perhaps it was Issah’s adroit driving skills that powered us through sometimes as much as 300km of dirt roads to reach these communities, but after just two days with Ernest (and his highly marketable energy if only extractable) and the community QI teams, I’m excited for my own project with the confidence that QI works successfully in resource-poor settings like Ghana. With more opportunities for these community teams to share, evaluate, and celebrate their work and even greater individual engagement with data, the results that Project Fives Alive will produce I think will exceed the already achieved success. Three cheers for Project Fives Alive!

Thank you again to Nana Twum-Danso and Ernest Kanyoke for this amazing opportunity to join you all for two days. I look forward to following Project Fives Alive as it continues to grow and spread.

For more information about IHI and Project Fives Alive, here are some relevant links:
Project Fives Alive Website
Fives Alive Project Description
On the Ground Account When IHI's Jane Visited Ghana

For more blog posts about my summer in Ghana, visit "Eva Ghana Wild"